4 StatisticsWorldwide, ~1 million people are traveling by air at any given time>700 million Americans travel by air in the US~one per 10-40,000 passengers will experience an medical emergency.U.S. Federal Aviation Administration. Moving America safely: annual performance reportSand M et al. Surgical & Medical Emergencies on board European Aircraft:10189 cases.

5 Goodwyn T: In-flight Medical Emergencies: an Overview.>50% of passengers age 50 or over have at least one health issue(s) Emergencies will become more frequent as % of elderly increasesGoodwyn T: In-flight Medical Emergencies: an Overview.Brit Med J 2000; 321:

7 63 passengers died in-flightThere are more deaths from in-flight medical emergencies than from airline accidents.In 2006:550 medical diversions59% were 50 or older63 passengers died in-flightNational Transportation Safety Board and Med Aire

8 In the Air, Health Emergencies rise quietlyUSA TODAY, Dec 2008The death of an AA passenger flying from Haiti to NYC has cast a spotlight on the growing number of medical emergencies on commercial jets, a trend that has escaped public notice because airlines aren’t required to report such incidents. A MedAire analysis shows that such incidents nearly doubled from , from 19 to 35 per million passengers.1 of 2

9 In the Air, Health Emergencies rise quietlyUSA TODAY, Dec 2008According to analysts, this is due to 2 factors:79 million baby boomers are entering retirement, but continue traveling habits established when they were young.Flights are going farther and lasting longer. Av. length of a flight in 2000: 1,233 miAv. length of a flight in2006: 1,347Max flying time today: 20 hrs2 of 2

10 “if you are ill, an airplane is the worst place to be…“… you are trapped at 35,000 ft.”David StemplerPresident of the Air Travelers’ Association.

17 The passenger cabin is pressurised to 1524—2438 mThe passenger cabin is pressurised to 1524—2438 m. This reduced pressure within the passenger cabin results in lower syst. PaO2 and oxyhaemoglobin (oyx-hb). For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension.Effect of cabin altitude on oxyhaemoglobin saturation(A) The aircraft passenger cabin is normally pressurised to an altitude of 1524–2438 m. This reduced pressure within the passenger cabin results in lower systemic PaO2 and decreased oxyhaemoglobin. For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension from 95 mm Hg (12·7 kPa) to 65 mm Hg (8·7 kPa) corresponding to an oxyhaemoglobin saturation from 95–100% at sea level (A) to 90% at a cabin altitude of 2438 m (B). (B) Passengers with pre-existing lower sea-level oxyhaemoglobin saturations have greater declines during a flight. In this example, a passenger with mild chronic obstructive pulmonary disease with a sea-level PaO2 of 70 mm Hg (A) and a FEV1 of 1·6 L (50% predicted) will have a corresponding reduction of PaO2 to about 53 mm Hg or oxyhaemoglobin saturation of approximately 84% at a cabin altitude of 2438 m (B). This passenger should be prescribed oxygen for air travel. PaO2=arterial oxygen partial pressure. FEV1=forced expiratory effort in 1 second.(A) The aircraft passenger cabin is normally pressurised to an altitude of 1524—2438 m. This reduced pressure within the passenger cabin results in lower systemic PaO2 and decreased oxyhaemoglobin. For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension from 95 mm Hg (12·7 kPa) to 65 mm Hg (8·7 kPa) corresponding to an oxyhaemoglobin saturation from 95—100% at sea level (A) to 90% at a cabin altitude of 2438 m (B).Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680:

18 Passengers with pre-existing lower sea-level oxy-hb sat have greater declines during flight.E.g., a passenger with mild COPD with a sea-level PaO2 of 70 mm Hg PaO2 to about 53 mm Hg or oxy-hb sat of approximately 84% at a cabin altitude of 2438 mEffect of cabin altitude on oxyhaemoglobin saturation(A) The aircraft passenger cabin is normally pressurised to an altitude of 1524–2438 m. This reduced pressure within the passenger cabin results in lower systemic PaO2 and decreased oxyhaemoglobin. For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension from 95 mm Hg (12·7 kPa) to 65 mm Hg (8·7 kPa) corresponding to an oxyhaemoglobin saturation from 95–100% at sea level (A) to 90% at a cabin altitude of 2438 m (B). (B) Passengers with pre-existing lower sea-level oxyhaemoglobin saturations have greater declines during a flight. In this example, a passenger with mild chronic obstructive pulmonary disease with a sea-level PaO2 of 70 mm Hg (A) and a FEV1 of 1·6 L (50% predicted) will have a corresponding reduction of PaO2 to about 53 mm Hg or oxyhaemoglobin saturation of approximately 84% at a cabin altitude of 2438 m (B). This passenger should be prescribed oxygen for air travel. PaO2=arterial oxygen partial pressure. FEV1=forced expiratory effort in 1 second.Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680:

19 Effect of cabin altitude on oxyhaemoglobin saturation(A) The aircraft passenger cabin is normally pressurised to an altitude of 1524–2438 m. This reduced pressure within the passenger cabin results in lower systemic PaO2 and decreased oxyhaemoglobin. For most healthy passengers, this results in a decrease in the arterial partial pressure oxygen tension from 95 mm Hg (12·7 kPa) to 65 mm Hg (8·7 kPa) corresponding to an oxyhaemoglobin saturation from 95–100% at sea level (A) to 90% at a cabin altitude of 2438 m (B). (B) Passengers with pre-existing lower sea-level oxyhaemoglobin saturations have greater declines during a flight. In this example, a passenger with mild chronic obstructive pulmonary disease with a sea-level PaO2 of 70 mm Hg (A) and a FEV1 of 1·6 L (50% predicted) will have a corresponding reduction of PaO2 to about 53 mm Hg or oxyhaemoglobin saturation of approximately 84% at a cabin altitude of 2438 m (B). This passenger should be prescribed oxygen for air travel. PaO2=arterial oxygen partial pressure. FEV1=forced expiratory effort in 1 second.Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680:

26 Is Air Travel Safe for those with Lung Disease?Coker RK et al. Eur Resp J 2007; 30:This prospective, observational study showed that 18% of passengers with COPD have at least mild respiratory distress during a flight.

40 OxygenMasks and nasal tubes available on board. Emergency bottles provide O2 at a fixed rate of 4 liters/min. Sufficient for 75 min.

41 Diversion can cost from US$10,000 to $100,000 depending on the routeMedication and technology are expensive but may still be cost-effectiveDiversion can cost from US$10,000 to $100,000 depending on the route

42 Equipment ChallengesAuscultation (pulm., BP) difficult due to ambient engine noise. Alternative: radial pulse palpation for syst BP.Aviation portable O2 bottles have only 1 of 2 settings: “low”=2 l/min and 4 l/min=“high flow”, far lower than flow used for EMS.O2 tubing for bag-valve resuscitation are not required to be compatible with these on-board O2 bottles.

43 Equipment ChallengesAEDs on board not required to have ECG screen, though ACLS meds are provided.When AED does have screen, it is limited to a leads II/paddles view.Glucometers not mandatory, though 50% dextrose is. Ask if any passenger on board would be willing to share personal glucometer.

44 Equipment ChallengesSince 9/11, phones have been largely removed from cabins and cockpit doors have been secured.Info must be relayed via intercomfrom the back of the planeor via flight attendant’s headset to pilots,who then relay infoto doctors on the ground

45 AED Automated External DefibrillatorAA first US airline to equip its fleet in 1997, first cardiac arrest save 1998.Mandatory for US commercial carriers. (Aviation Medical Assistance Act).Aircraft with inoperable AEDs are allowed to make “a few flights” until a replacement can be found.

46 AED Automated External DefibrillatorAEDs are still not mandatory for European commercial carriers (European Aviation Safety Agency).No AEDs on Intercity aircraft in Europe.

47 Positioning the PatientRemove patient from seat, grippinghim/her from behind.

48 Positioning the PatientIf possible, position potential emergencies next to the aircraft’s door or in the galley, horizontal to flight direction against front wall.Make sure all trolleys are secured.Stueben, U. Flugmedizin/Flight Medicine.Medizinisch Wissenschaftliche Verlagsgesellschaft Berlin, 2008

49 Make sure there is enough space behind pat’s head in case of intubationMake sure there is enough space beside pat’s chest in case of cardiac massage

50 Telemedicine: MedAireGround-based service utilized by airlines. VHF radio or satellite phone contact to ED physicians at MedAire. Arizona-based company providing emergency med advice to airlines carrying ~half of the 768 million passengers on US flights each year. Takes responsibility for deciding if flight diversion is appropriate.

58 Time Zone Changes & altered Meal TimesHypoglycemia in insulin dependent diabetics though diabetic meals can be provided.Passengers on other strict drug regimens, (e.g. for epilepsy)Passengers who have packed their medication in the hold.

65 Responding to in-flight Medical Events 1Be prepared to show med credentials or answer questions about degree or trainingObtain consent from affected passenger. Assume implied consent when passenger is incapacitated or unresponsive.Do not fear litigation. Physicians have been deposed, but no litigation has ever been brought forward against a responding physician.

66 Responding to in-flight Medical Events 2Request and establish communication with the airline’s ground med support for advice and consultation regardless of how minor or serious the in-flight event is.Request the enhanced emergency med kit (many airlines initially offer basic first-aid kit) but do not open it unless needed. Each kit has a placard listing contents.Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680:

71 Altering Cabin PressureCabins are pressurized but airlines can legally alter pressure to the equivalent of 8000 ft.

72 Emergencies in the AirQureshi A, Porter KM. M. Emerg Med J 2005; 22:Exacerbation of pre-existing medical problems caused the vast majority of in-flight emergencies (65%).Respiratory problems were most common. 50% asthma-related, 33% due to forgotton medication.Syncope accounted for 25% of all incidents and 91% of all new medical problems.

73 Hypertensive Crisis Urapidil available on all aircraftNitro Spray and/or capsules available on all aircraftOral calcium antagonists available on some aircraftConsider Diff Dg: Stroke, MCI,hemorrhage from ruptured aneurysm, thusMedical diversion if possible

77 Silverman D, Gendeau M. The Lancet 2009; 373/9680: 2067-77Cardiac ArrestPlace AED on patient. Some defibrillators incorporate a rhythm display that can help making decisionsFollow BLS or ACLS resus algorithmsIf resuscitation is stopped because of no return of spontaneous circulation, pt should not be pronounced dead officially on international flights (medico-legal reasons)Silverman D, Gendeau M. The Lancet 2009; 373/9680:

78 US Government Air Carrier Access Act May 2008All US-based air carriersand foreign air carrier flightsthat begin or end in the USAmust accommodate passengers who need portable oxygen concentrators.Non-discrimination on the basis of disability in air travel. Final Rule. Fed Regist 2008; 73:

80 PneumothoraxThe effect on pneumothorax was well publicised when, on a flight from Hong Kong to London, Professor Angus Wallace relieved a tension pneumothorax with the aid of a catheter, coat hanger, and brandy bottle.Wallace WA: Managing in flight emergencies. BMJ 1995; 311:1508

85 an event about to happen.Extended travel with limited movement & rehydration are THE recipe for pulmonary embolism.Add factors like birth control pills, obesity, age and/or smokingand you are pretty muchan event about to happen.

86 Anticoagulants for Air Travel?No formal guidelines existStill controversial, though RC trials show benefit of LMWH for air travelers at moderate risk who do not take anticoagsAspirin is not recommended alone as prophylaxis for any air traveler.Kuipers S et al: Travel and venous Thrombosis: A systematic review. J Intern Med 2007; 262:

91 Does a medical professional who is a passenger have a duty to volunteer medical assistance?US, Canada and the UK: NO, unless there is a pre-existing patient relationship.International law: country in which aircraft is registered has jurisdiction. However, country in which incident occurs and country of citizenship of plaintiff or defendant can also have jurisdiction.Hedouin V et al: Medical Responsibility and Air Transport. Med Law 1998; 17:

92 Medicolegal Recommendations1. Identify yourself, state your medical qualifications. Some airlines require proof of your medical qualifications.2. Obtain as complete a history as possible, inform passenger and family members (if present) of your impression, obtain consent before initiating any form of examination or treatment. Assume implied consent if pg. is incapacitated.Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14:

93 Medicolegal Recommendations3. If consent has been given, carry out an appropriate physical examination.4.Request an interpreter if the passenger you are assisting does not speak your language.5. Inform flight crew of your impression.6. If condition is serious, request aircraft to be diverted to nearest appropriate airport.

96 The Aviation Medical Assistance Act“ An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight med emergency unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct.”

97 The Aviation Medical Assistance ActLimits liability for volunteering physicians under the assumption that they act in good faith, receive no monetary compensation and provide reasonable care. Gifts, such as seat upgrades and liquors are not considered compensation. Pertains to events that occur within US airspace and aircraft registered within the US.

99 Medicolegal RecommendationsKeep in mindthat “good Samaritan” statutes protect you only from liabilityfor actions that other competent persons with similar trainingwould take under similar circumstances.Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14:

100 Never officially pronounce a passenger dead, even if you assess that resuscitation is futile and cease treatment, especially on international flights.Silverman D, Gendeau M: Medical issues associated with commercial flights. The Lancet 2009; 373/9680:

101 Up in the Air – Suspending Ethical Medical PracticeShaner, M. New Engl J Med 2010; 363/21:We were flying from the East Coast to the West. About midflight, a lady behind us reached frantically for the baggage bin. She was trying to get her husband’s oxygen tank. He looked about 70, eyes closed, right hand clutching his chest, grimacing in pain. Suddenly, his grimace faded and his arm dropped. Leaning over, I felt for a pulse. There was none. A flight attendant approached. “I am a physician,” I said. “Let’s get him down to the floor.”

102 Up in the Air – Suspending Ethical Medical PracticeShaner, M. New Engl J Med 2010; 363/21:We were flying from the East Coast to the West. About midflight, a lady behind us reached frantically for the baggage bin. She was trying to get her husband’s oxygen tank. He looked about 70, eyes closed, right hand clutching his chest, grimacing in pain. Suddenly, his grimace faded and his arm dropped. Leaning over, I felt for a pulse. There was none. A flight attendant approached. “I am a physician,” I said. “Let’s get him down to the floor.”

103 Up in the Air – Suspending Ethical Medical PracticeShaner, M. New Engl J Med 2010; 363/21:We lifted him into the aisle. I shined a pocket flashlight on the dimly lit scene. He had stopped breathing; no pulse. Three other passengers joined us, an anesthesiologist, an oncologist and a surgeon. My wife ran the code, I provided chest compressions, the anesthesiologist bagged the patient, the oncologist managed the equipment, the surgeon put in an i.v. and then injected epinephrine intracardially.

104 Up in the Air – Suspending Ethical Medical PracticeShaner, M. New Engl J Med 2010; 363/21:We followed the protocol suggested by the AED. It did not discharge: its rhythm-detection program found no rhythm that might be treated with defibrillation. The monitor showed a wide complex bradycardia with which we could not associate a palpable pulse. After 25 minutes of basic cardiac life support, there was still only pulseless electrical activity. The 5 physicians agreed:it was time to stop and declare the patient dead.

105 Up in the Air – Suspending Ethical Medical PracticeShaner, M. New Engl J Med 2010; 363/21:The flight attendant explained that if we stopped CPR, the airline’s protocol would require the cabin crew to continue it. In other words, CPR was going forward whatever we decided. We chose to continue it ourselves so that the four flight attendants could attend to their duties during an emergency landing. We landed 45 min later. The patient died the same day.

110 Keep in mind that “good Samaritan” statutesprotect you only from liabilityfor actions that other competent persons with similar trainingwould take under similar circumstances.Gendreau MA, DeJohn C. N Engl J Med 2002; 346/14: